Monthly Archives: June 2015

Dylann Roof suffered from two delusions. The first was that the actions of others, that specific groups of others were responsible for his own distress and failures, his limitations, his hopeless future. From the little we know of him, I think we can assume his target might have been a different group of others, perhaps Jews, in another place and time and context.

The second delusion was that he, an undereducated, unemployed 21 year-old boy, could and should engage in a single act of violence that would, he believed, change the course of history.

How should we think of this, beyond such words as racism, terror, evil, horror, derangement, and tragedy?

If we want to prevent this happening again we do need to try to understand it. We do need to understand if this was a singular inexplicable event, ultimately unpredictable and not preventable, or the failure of the mental health system, the correctional system, the educational system, the policing system, or one vulnerable kid acting on both the subliminal and overt attitudes of many others.

The human brain, especially the 21 year-old human brain, craves explanation, organization, ways of understanding its perception and experience. It especially demands ways of understanding failure, distress, fear and limitations. And up to a point it is natural in the adolescent phase of development to blame others: teachers, parents, rules, cops, peers, the referee, bad luck. In different times and different contexts this young brain is easily directed by propaganda to blaming Jews, Infidels, Apostates, Indians, Chinese, The Government, Hispanics, Blacks.

One of the jobs of parents and teachers is to adjust these assumptions and conclusions, sometimes gently, sometimes decisively.

By 21 we hope our children have learned to assume some personal responsibility, that their brains are figuring out and accepting the nuances and subtleties of cause and effect, of external and internal control, of responsibility. We hope that they are developing some empathy for others, even others quite different from themselves.

We also hope that their assessments of themselves within this world are beginning to be grounded in reality.

That first delusion. We can arrive at that first delusion, the belief that a group of relatively disenfranchised others (not crooked politicians, recessions and depressions, wall-street barons, lack of educational opportunities) are ruining our lives, through two routes.

The first may be actual, definable, treatable, mental illness: The inability to engage with others, to share information, to process all the complex nuances of interpersonal life, an inability to understand messages of avoidance, of intimacy, of competition, of friend or foe, and because of this, an inability to gain a realistic appreciation of how I fit in, of who is responsible for what.

A delusion satisfies the craving for explanation. But when a delusion is the product of illness it is usually very autistic, a conclusion that one’s life is being controlled by a microchip or radio waves, for example. Though it is quite possible for an ill person to further conclude that certain person(s), or a non-human for that matter, are behind this nefarious plot. The delusion derived from illness, from schizophrenia or depression or mania, does not need corroboration. It does not need anyone agreeing with it. It does not need sanction. And thus it is usually seen by everyone else as crazy, improbable, if not impossible. It is usually suffered privately. It is usually only harmful to self and family. And, of course, it is treatable.

But it is not necessary to have a brain illness, a biological cognitive deficit to come to terrible conclusions. It can arise from reaching 21 still blaming others, still searching for external answers to explain one’s limitations, fears and failures. And from a failure of parents to nudge that teen to healthier schemata, and from access to information, propaganda, symbols and persuasive people who tell this boy, “It is not your fault that you are helpless, useless, hopeless, that you can’t get a girl or a job. It is their fault.”

And then this boy looks around his neighbourhood and sees that many others quietly believe the same. And now on the Internet he can find a revisionist history and many persuasive (persuasive if one’s knowledge and maturity are limited) voices exhorting the same viewpoint. “It is their fault. They are taking away my power, control, my future.”

So for Dylann Roof this was, in a non-clinical sense, a delusion. The externalization of control and blame. A belief shared by too many others. But it was not the autistic delusion that emanates from a treatable psychotic illness.

The second delusion is more problematic. Dylann came to believe that he could and should engage in a single violent act that would change the course of history. Without this second delusion he might have spent his life sober, drunk, employed or unemployed, living with someone, or living alone in a cabin in the woods, occasionally, especially when drunk, upsetting people with a racist rant.

But he came to the manic, grandiose conclusion that he, an uneducated unemployed boy with an average I.Q. and no notable skills or talents, no formal allegiances, should do this thing. But he didn’t behave in a manic fashion, simply grandiose and narcissistic, and without empathy. Perhaps he was simply sufficiently narcissistic, sufficiently naïve, sufficiently sociopathic, to believe he could do this thing, cause a revolt, change the course of history, and be hailed as a hero.

He could read the symbol on the flagpole of the South Carolina Statehouse. He could fill himself with hate propaganda on the Internet, all of which would overtly or covertly demand action. And he could absorb the subliminal messages all around him, even in the street names of Charlestown.

The tool to do this thing was easily available. He did not need a complex plan to acquire and conceal a gun. He bought it and carried it.

So, how do we prevent another of these events?

A better mental health system would be fine, but might not have helped Dylann. This was probably not, strictly speaking, the product of a treatable mental illness.

A more functional and stable family? Yes. But we have no way of making this happen.

A better educational system? Yes. Definitely. And one that offers alternative programs for those inclined to drop out.

Good, dignified employment. Yes. Let’s work on that through social policy at all levels of government.

Gun control? Yes. Definitely. It is social and legislative insanity to let a 21 year old buy any guns, let alone handguns. Pure and simple. It should not happen. And while murder can be committed by other means, those other means are not as deadly, not as easy, and not as amenable to a momentary impulse.

And then we have communal attitudes, overt attitudes, subliminal attitudes, and symbols of hatred, fear and racism. They have a lot of work to do down there. Leaders need to watch the language they use (e.g. “Take back our country”) lest it be mistaken for a call to arms by the less stable among us. And the symbols. The State could quickly remove those symbols of defiance and racism and confine them to the museum. And the State could take a leaf from Germany and ensure the present generation understands and appreciates the truth of their country’s past.

Well, so far, though it looks like Dylann Roof’s name will be long remembered, his actions may have brought about something quite opposite to what he imagined.

I am tired of the mind/body argument, the dichotomy. I am tired of hearing about “new” models, theories, and psychotherapy processes, new gimmicks. I am as tired of the overreaching DSM IV and V as I am of mental illness denial.

Here is what a psychiatrist actually does, or at least what I do:

I read whatever information is given to me about the patient I am about to see. From this I am already formulating some lines of inquiry, some hypotheses to be considered. The one certainty at this moment is that I am seeing these people because they have a problem and they want help.

As my patient or family enters I am watching them, how they interact, how they sit, walk, speak, what their eyes are telling me. I say or do something to break the ice, from the weather to the news to the book the eleven year-old is clutching or the new Blackberry his mother is putting back in her purse, or the pink Samsung the teenager is holding as if it were a lifeline to planet Earth.

And then I ask questions and listen and watch. The questions are not random but neither are they detached from the reality in the room. Some are derived from science and experience, some from high and low culture; some are designed to ease my patient’s or family’s journey to full disclosure of the whole story. And right from the beginning and throughout this process I am asking myself if I should be thinking of this, this problem unfolding, as an illness, an illness derived from its biological origins, or as a psychological reaction to something, as a parenting or family problem, even sometimes as a broader social problem, a misfit of school and child, as a serious harbinger of a life long deficit, or merely a developmental stage, a passing thing, and even if it might really be no problem at all, just a bump in the messiness of life. And always, how much is this present realty, this “talking to a psychiatrist”, impacting the story I am hearing?

Sometimes I know the answer to these questions by the end of the appointment. Sometimes I know that I will not know the full answer for a month or a year or two. Sometimes I fear I will never know.

But, far more importantly, I am also asking myself these questions: Is someone suffering? How badly is he or she suffering? Do I (we) have the means to alleviate this suffering? And my choice of the means to alleviate this suffering will depend on the patient and her family’s feelings, thoughts, convictions as much as my own interpretations and conclusions. And of course, that prime directive, “Do no harm.”

But, if you have sat on a mattress beside a young man in a full-blown schizophrenic psychosis, or paced the corridors with a manic librarian, or sat for any length of time with a woman in a state of agitated depression, or debilitating obsessions, you will know that a.) There is a lot of suffering here, and b.) These are brain things, biological illnesses.

It is not an uncomplicated matter. The modern concept of disease has only been with us a hundred and fifty years or so. And this very concept, this idea of disease, could well be the reason you are alive reading this now, and did not die from diphtheria, pertussis, polio, perhaps cancer – or be more crippled than you are with arthritis. It is also the concept that has allowed us to successfully treat severe depression, mania, psychosis.

I am sure some of my colleagues over-use the illness/disease concept when trying to understand a perplexing behaviour. And some I know under-utilize it. I’m sure I get it wrong sometimes. And many non-physician mental health workers simply apply the feel-good concept of the month, or bypass any attempt to understand the problem, it’s roots and pathways, and focus instead on strengths and goals and those things that we all know contribute to a healthier life.

Fair enough. But instead of arguing about concepts of illness/disease/mind/brain/body, we should focus on relief of suffering, and helping someone return to a level of functioning he or she desires, and we should use all the tools in our tool box to accomplish this, providing we have evidence they actually work.

In a recent Huffington Post blog, Susan Inman (After Her Brain Broke: Helping My Daughter Recover Her Sanity), wrote about the need for greater literacy about mental illness. And, like me, Susan often gets inundated with comments from opponents. One was from John Read, a psychologist at the University of Melbourne.

Susan was arguing that we need greater understanding of the biological causes of serious mental illness and I agree. Read, however, commented that:

“The evidence is over 50 studies all showing that biological beliefs increase fear and stigma. I’m afraid you are swallowing drug company propaganda, there is no evidence that these drugs prevent violence.”

When challenged to provide sources, he countered with:

“If anyone is interested in what the reserch (sic) says on this issue……

In an article that I wrote for the World Fellowship for Schizophrenia and Allied Disorders in 2010, I mentioned the Read approach. Basically that approach states that we should ignore the illness in favour of viewing mental health problems as part of our shared humanity. One of the research papers by Read that I commented on was a 2002 paper which compared the biological explanation of mental illness to a psychosocial explanation. And while Read points out that the psychosocial explanation helped reduce stigma more that the biological, he admits there was no statistical difference between the two.

This is the link to his first article that he cited in his comments to Ms Inman. You can decide but note the lack of objectivity in his title. Biological explanations are cited as ideology that are promulgated and schizophrenia is in quotes. The second paper he cited deals mostly with surveys asking people what they considered to be the causes of mental illness. Many of them believed that the causes were psychosocial which just proves that Susan Inman is correct in wanting to see greater literacy.

But again, to prove his point, he says that a study that showed a video of a person describing their psychotic experiences increased perceptions of dangerousness and unpredictability in viewers. However, a video explaining the same experiences in terms of adverse life events, led to a slight but non significant improvement in attitudes by those who viewed it.

Again with the non significance. It means there was no difference between the two. The responses were the exact same! Someone who acts scary and displays very abnormal and aberrant behaviour is going to be shunned regardless of the explanation for that behaviour. He does cite a number of papers but they date from 1955 to the latest in 2005.

In my 2010 article, I quoted Dr Heather Stuart, an expert in stigma at Queens University in Kingston, Ontario who said that there have only been six controlled studies of stigma. One of them by Patrick Corrigan found that education did lead to improved attitudes. I could not find a reference to that paper in the one by Read.

As an example, those with advanced symptoms of Hansen’s Disease looked very frightening and were isolated from society. The Leper Colonies existed because no one understood the disease and were afraid they might get it too. But then, modern medicine came along, discovered Leprosy was caused by a bacteria, learned to treat it early and we no longer have people disfigured when treated early. We might still cringe at the thought of leprosy but likely no one has ever seen an advanced case.

In a similar vein, the solution for schizophrenia stigma is not to pretend it isn’t what it is but to provide treatment. As Queen’s University psychiatrist Julio Arboleda-Flores said in his 2003 editorial in the Canadian Journal of Psychiatry, “the best approach is to limit the possibilities for people to become violent via proper and timely treatment and management of their symptoms and preventing social situations that might lead to contextual violence;” he writes that “this could be the single most important way to combat stigma.”

And one way to ensure that is to have greater mental illness literacy as Susan suggested.

Now I also have to comment on a post to Susan’s blog by someone who is continually criticizing both Susan and I for our writing on the medical model for schizophrenia. Suzanne Beachy did post a number of comments which you can see for yourself but my favourite is her announcement that another critic of the medical model, Rossa Forbes, has just announced that her son is cured of his schizophrenia.

It seems that his cure was delayed by their being “sidetracked by institutional psychiatry perpetrating the false belief that there was something gone horribly wrong with his brain and only they knew the magic formula to set things right again.” If you go to Ms Forbes blog, you will see her extolling how well her son now is which is wonderful. In fact, she says, he is so well that he has reduced his Abilify to half its dose and is planning to go completely off slowly over time. Abilify, of course, is an anti-psychotic used to treat schizophrenia and is prescribed by psychiatrists.

Those disparate thoughts and memories floated through my mind (Part I) after watching a disturbing documentary about ISIS/ISIL/IS and especially the sequence of young boys, coached by older boys, waving their rifles at the camera and shouting their slogans of death.

And then another disparate memory arrived. In my youth I was a fan of science fiction, but I have always been puzzled by this: When science fiction writers need to describe and explain or create a system of governance for a far off planet in another galaxy (or on earth) in the distant future, either as background for the warp speed adventure or as an integral part of the story, they create kingdoms, oligarchies, dictators with near magical powers, serfdoms, master/slave relationships, warring tribes, and people who have achieved technological wonders and then returned to till the land in small communes, where everybody dresses in white, speaks Olde English, and worships at sunrise.

Even King Farouk of Egypt was more optimistic than our science fiction writers when he said something like, “Soon there will be only five kings in this world: the king of hearts, spades, clubs, diamonds and the king of England.”

I get it. Liberal, inclusive democracies are boring. Peter MacKay has stepped down. He is leaving the caucus, retiring from politics. We will work hard to find some palace intrigue behind this move, but, if there is any, it will be vague, arcane, unsubstantiated, and unexciting. I am glad I live in this country.

But there is something here to consider. An advanced form of governance, a liberal democracy with an independent judiciary is the product of social evolution. It is not the product of biological evolution, though it is our ability to use language, to empathize, to engage in abstract thought that has made it possible. But it is not biologically natural. If it were, then our teenagers would be watching the parliamentary debates rather than Game of Thrones. And as soon as they were allowed they would be voting in all elections.

So, let’s face it, our inclusive liberal democracy, precious as it may be, continuing to evolve and, we hope, improve, is an overlay – an overlay on top of some pretty primitive impulses, some ancient DNA.

And what do these thoughts mean, if anything? I think this: If we happen to survive global warming, if those primitive impulses don’t trigger a nuclear war, and if the sun waits a billion years or so before exploding, we need to acknowledge this commonality, this biological reality. We are not made in God’s likeness; we are not born without a program; we are not inherently good; we are, to quote Star Trek, “ugly bags of mostly water”; and the DNA that served us well as Homo Habilis and Homo Erectus, remains within us sleeping under a thin layer of civilized instruction.

If you don’t believe this, just think of the astonishing stupidity of shouting FHRITP on camera.

So apart from all the other things we need to do to make this planet a better place, we need to accept the reality of being partially evolved biological entities with limited life spans, discard all old and new age religions that bestow some form of divinity upon us, and educate, educate, educate.

And the next time I interview an 18 year-old, I would like to find that he or she has at least a rudimentary understanding of the evolutionary history, the importance, and the fragility of our democracies and our inclusive social contract.

In the 1960’s we sat on the beach around a fire looking across the inlet to a few lights on the north shore, the moon rising in the east. The guitarists among us played freedom songs, folk songs, union songs, anti-war songs, love songs. We passed a joint or two around, drank cheap beer and wine, and sang.

We were confident, I think, that eventually the Americans would see the folly of the Vietnam War, there would not be a World War III, the iron curtain would collapse, and Russia would eventually find its way to the virtue of a mixed economy and full democracy. Universal health care was on its way. The women among us used birth control, looked forward to careers of their own.

We may have imagined having children at the time, though certainly not grandchildren. But had we imagined having grandchildren I think we would have imagined bequeathing them a world made up of mostly civilized countries gathering at the UN to discuss their mixed economies and their inclusive democracies. We could have guessed, I think, that they would also be discussing excess use of petroleum (or running out of it as some thought would surely come to pass), preserving the forests and wildlife, protecting endangered species, providing education for all, and eliminating poverty.

Fast forward to 2015 and a few countries, including Canada, do have universal health care. The Iron Curtain is gone. Despite Vlad’s wish to be Czar, Russia is getting there. We are certainly talking about petroleum, wildlife, forests and oceans. We continue to argue about the right mix in ‘mixed economies’. Not such high marks on education and poverty.

And then we have ISIS/ISIL and terrorism. Who would have guessed?

In Egypt the army is once again in control. A generational slippage, a step backwards, as often happens in the long, tedious, evolutionary road to an inclusive democracy and a better social contract.

But ISIS and terrorism. That’s not slippage, a step backwards, a pause, a stall. That is some unleashing of the remnants of very primitive DNA in the young male brain. Some instruction that may have served them well as they rode with Genghis Khan, or fought over a watering hole in the jungle, or reverted to cannibalism when other protein was scarce. Some thousands of years ago.

We have two boxer dogs. They can bark at perceived intruders, chase squirrels up trees, make birds take flight, but they are gentle, crave touching and play, and they are overly affectionate with friendly humans. Lovely dogs. But last summer an overweight ground hog, probably the patriarch of a brood in the nearby bushes, wandered onto our dogs’ territory looking for mulberries. The dogs moved quickly. Working as a team they cornered this hapless creature. And then they tore him apart.

Well, as a species our dogs are only a few hundred years from a time when this particular behaviour was required of them to eat, protect their families, and survive. So we have forgiven them. Besides, they don’t have language. It is impossible to teach them and explain to them that level of differentiation, consideration and nuance. And they did not invoke God and his ancient texts in the act of killing.